The Vanishing
Physician-Scientist?
Andrew I. Schafer
Chairman, Department of Medicine
Weill Cornell Medical College
Indiana University School of Medicine
April 26, 2011
Physician-Scientists



Conduct medical research along
entire continuum
Devote majority of effort to research
Vital and unique role in medical
research enterprise
Original “endangered
species” article:
Evolving Role of Physicians
in Medical Research
The 19th Century and Earlier
•
Physicians make most major contributions
to medical knowledge
Evolving Role of Physicians in
Medical Research
The 19th Century and Earlier
•
Physicians make most major
contributions to medical
knowledge
Andreas Vesalius(1514-1564)
Founder of Modern Human
Anatomy
Foundation of medicine as
“observational science”
Evolving Role of Physicians in
Medical Research
The 19th Century and Earlier
•
Physicians make most major
contributions to medical
knowledge
William Harvey (1578-1657)
Foundation of medicine as
“functional science”
Evolving Role of Physicians in
Medical Research
The 19th Century and Earlier
•
Physicians make most major
contributions to medical
knowledge
Claude Bernard (1813-1878)
Founder of modern
experimental medicine
Evolving Role of Physicians in
Medical Research
The 19th Century and Earlier
•
Physicians make most major
contributions to medical
knowledge
Rudolph Virchow (1821-1902)
Cellular basis of disease
Evolving Role of Physicians in
Medical Research
The 19th Century and Earlier
•
Physicians make most major
contributions to medical
knowledge
Robert Koch (1843-1910)
Germ theory of disease
Evolving Role of Physicians in
Medical Research
The 19th Century and Earlier
•
Physicians make most major
contributions to medical
knowledge
Louis Pasteur (1822-1895)
(Chemist)
Germ theory of disease
Evolving Role of Physicians in
Medical Research
1890s - 1930s
•
•
•
•
Dramatic rise of science and research in
medicine
Science becomes integral to medical
education
Inspired by clinical observations
“bedside to bench”
Research labs located in hospitals
Evolving Role of Physicians in
Medical Research
1930s - WWII
•
•
•
•
•
Dramatic therapeutic advances heighten
glamour of medical research
Rising public opinion of medical research
Philanthropy
Physicians (and increasing number of PhDs)
doing basic research that is becoming more
detached from clinical relevance
Interrupted by WWII, when researchers
support war effort by returning to applied work
Evolving Role of Physicians in
Medical Research
WWII – 1970s
•
•
“Golden Age”
Vannevar Bush: primacy of
fundamental research
Vannevar
Bush
SCIENCE:
THE ENDLESS FRONTIER
Vannevar Bush
A Report to the President by the Director of
the Office of Scientific Research and
Development
United States Government Printing Office, 1945
Evolving Role of Physicians in
Medical Research
WWII – 1970s
•
•
•
“Golden Age”
Vannevar Bush: primacy of
fundamental research
Burgeoning of NIH: strong basic
sciences orientation
Dedication
of the New
NIH
Campus in
Bethesda
1940, FDR
Evolving Role of Physicians in
Medical Research
WWII – 1970s
•
•
•
•
•
“Golden Age”
Vannevar Bush: primacy of
fundamental research
Burgeoning of NIH: strong basic
sciences orientation
PhDs flood medical research arena
Age of “triple threat” MD
Evolving Role of Physicians in
Medical Research
1970s •
•
•
Basic and applied research becoming
polarized
Mounting pressure from Congress and
public advocacy groups for practical
payoff in conquest of disease
“Bench to bedside”
Evolving Role of Physicians in
Medical Research
1980s -
•
•
Rising concern about future of
physician-scientist
IOM, NIH, AAMC reports on “clinical”
research
Percentage Increase in First Time
R01 Applicants (1998-2003)
120%
100%
80%
60%
43%
40%
20%
0%
PhD
-20%
Percentage Increase in First Time
R01 Applicants (1998-2003)
120%
104%
100%
80%
60%
43%
40%
20%
0%
PhD
-20%
MD-PhD
Percentage Increase in First Time
R01 Applicants (1998-2003)
120%
104%
100%
80%
60%
43%
40%
20%
-4%
0%
PhD
-20%
MD-PhD
MD
1980
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
1981
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
1982
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
1983
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
1984
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
1985
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
1986
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
1987
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
1988
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
1989
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
1990
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
1991
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
1992
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
1993
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
1994
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
1995
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
1996
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
1997
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
1998
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
1999
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
2000
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
2001
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
2002
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
2003
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
2004
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
2005
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
2006
7%
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
2006
7%
1980
6%
Percent of PIs / Faculty
5%
4%
NIH RPG PIs
Med School Faculty (AAMC)
3%
2%
1%
0%
25
30
35
40
45
50
55
60
Age
Sources: IMPAC II Current and History Files and AAMC Faculty Roster
September 2007, Age Distribution of NIH RPG Investigators and Medical School Faculty
65
70
75
80
85
90
Attrition of NIH-Funded
MD-Scientists

About 40% of MDs with K08 (mentored clinical
scientist development) awards do not even apply for a
subsequent R01 grant.
Kotchen, JAMA, 2004



First-time unsuccessful MD applicants for an R01
grant are consistently less persistent than PhD
applicants in reapplying.
MD applicants with an R01 grant are less likely than
PhD applicants to apply for a subsequent R01 grant.
At every point in the early life cycle of NIH funding,
MD-scientists are more likely than PhD-scientists to
leave the R01 grant application pool.
Dickler, JAMA, 2007
Chasm
between
Basic Science
and Clinical
Practice
Chasm Between Basic
Science and Clinical Practice

Scientific
Bridging the Chasm
Bridging the Scientific Chasm
between Basic Science and
Clinical Practice

Integrationism of systems biology

Translational research

Evolution of physicians as members of
research teams
Chasm Between Basic Science
and Clinical Practice

Scientific

Cultural
Cultural Barriers Separate
Clinical Medicine from Basic Science
(from Barry S. Coller)
Need for
Immediate Action
Adherence to
standards of
practice
Avoiding Rush to
Judgment
Encouragement
to challenge
existing
paradigms
Cultural Barriers Separate
Clinical Medicine from Basic Science
(from Barry S. Coller)
Respect for
hierarchy and
expert authority
Critique,
challenge
accepted wisdom
Errors as mortal
threats
Errors as inevitable
manifestations of
creative process
Cultural Barriers Separate
Clinical Medicine from Basic Science
(from Barry S. Coller)
Focus on unique
Focus on
generalizable
principles
Commitment to the
Physician’s Oath
Commitment to
Search for the Truth
Bridging the Chasm
Bridging the Cultural Barriers
between Basic Science
and Clinical Practice





Vive la différence
Institutional leadership to cultivate a
climate of mutual respect and trust
Research team building
MD trainees experience laboratory
research
PhD trainees experience clinical
medicine (e.g. HHMI “Med Into Grad”
Initiative)
“Young MDs and PhDs have much to teach each
other from two different vantage points…led
me to wonder whether young MDs and PhDs
are not ideally equipped to train each other.”
-Edward H. Ahrens, Jr.
The Crisis in Clinical Research, 1992
Major Contemporary Issues in
Physician-Scientist Career
Development
1.
Women physician-scientists
Women Physician-Scientists
Gender Distribution of Matriculated
Medical Students
Why Women Find Physician-Scientist
Careers Less Attractive Than Do Men




Concerned that it will be impossible to
combine a successful career with
childbearing and family life
Feel that they have to be better than their
male counterparts to be considered equal
Receive little encouragement to become
physician-scientists
Lack compelling role models
- Andrews, NC. Nature Med, 2002.
Major Contemporary Issues in
Physician-Scientist Career
Development
1.
Women physician-scientists
2.
Generation gap in expectations
“There’s a tremendous generation gap between
what the current generation of junior faculty
want and what the current generation of
senior faculty perceive as correct.”
-Junior male faculty MD-scientist,
Duke Faculty Focus Group
Male executive survey question: “I want job
options that let me have more personal time”
Somewhat
disagree 12%
Strongly
disagree
4%
Strongly
agree
48%
Somewhat
agree
36%
Source: Jody Miller, “Get a Life!” Fortune, November 28, 2005
Percentage of all households in the U.S.
Changing Family Structures
1.8%
3.5%
5.9%
10.8%
12.8%
20.4%
24.2%
Male Single Parents
Female Single Parents
Other Families
40.6%
Dual-worker Families
Traditional Families
63.4%
17.4%
1950
Years
Years
2005
Source: Benko C, Weisberg A. Mass Career Customization: Aligning the Workplace with Today’s
Nontraditional Workforce, 2007.
“What about the wife and babies if you
have them? Leave them. Heavy are the
responsibilities to yourself, to the
profession and to the public. Your wife
will be glad to bear her share of the
sacrifices you make.”
William Osler
(NYT 4.2.11)
Memorandum from Einstein to
Mileva Einstein-Maric
18 July 1914
A.
B.
C.
You will see to it that:
1. My clothes and laundry are kept in good order;
2. I will be served three meals regularly in my room;
3. My bedroom and study are kept tidy, and especially that my desk is left for
my use only.
You will Relinquish all personal relations with me insofar as they are not
completely necessary for social reasons. Particularly, you will forgo my:
1. Staying at home with you;
2. Going out and traveling with you.
You will obey the following points in your relations with me:
1. You will not expect any tenderness from me, nor will you offer any
suggestions to me;
2. You will stop talking to me about something if I request it;
3. You will leave my bedroom or study without any back talk if I request it.
(reference: Collected Papers of A. Einstein, Vol. 8, p. 32)
The New Workforce Imperative
Corporate Ladder:
Traditional hierarchy
Linear path upward
Move or stop moving
Fits traditional family structure
Assumes workers’ needs remain consistent over time
Corporate Lattice:
Multiple, individualized paths upward
Move faster, slower; change directions
Personalized career-life fit
Adjusts as workers’ needs change over time
Adapted from Benko, Weisberg: Mass Career Customization, 2007.
Off-Ramps and On-Ramps: Keeping
Talented Women on the Road to Success
(Harris survey of 2400 “highly qualified” professional women and 653 men ages 28-55)



Two thirds of highly qualified women
have discontinuous or nonlinear
careers
93% of women who stepped out of
the workforce want to return to their
careers
Most organizations are ill equipped to
make reentry possible, let alone easy
-Hewlett SA, 2007
Flexible Faculty Policies Related to
Tenure and Promotion
1.
Extend length of the probationary period
2.
Tenure (promotion) clock-stopping policy
3.
Less than full-time employment while on
a tenure-eligible track
Probationary Periods ≥ 8 Years for
Basic Science and Clinical Faculty in
the U.S. Medical Schools 1983-2008
Evolving Workplace Flexibility for
Medical School Tenure-Track Faculty
(Bunton SA, Corrice AM, Acad Med, 2011)




Despite the existence of these policies, results bring into
question the acceptance of their use in the culture of
academics
Many institutions may have developed flexible policies but
implicitly or explicitly discourage faculty members from
using them
In fact, some faculty members may fear retribution for
using these policies despite their availability
There is a disconnect between the existence of policy and
faculty knowledge about or willingness to use it, which may
reflect lingering employment norms
Major Contemporary Issues in
Physician-Scientist Career
Development
1.
Women physician-scientists
2.
Generation gap in expectations
3.
Mentoring
Characteristics of a Mentor
Mentor
Teacher
Sponsor
Advisor
Role Model
Coach
Confidant
Characteristics of a Mentor
Mentor
Mentee
Teacher
Pupil
Teacher
Sponsor
Protégé
Sponsor
Advisor
Advisee
Advisor
Role Model
Novice
Role Model
Coach
Trainee
Coach
Confidant
Communicator
Confidant
Major Recommendations
1. Attention and resources
should be directed at
repairing the “leaking”
physician-scientist
pipeline.
Major Recommendations
2. Major changes
should be made to
the contemporary
approach to
mentoring
physician-scientists.
Major Recommendations
3. Institutions should
proactively promote
the advancement and
minimize the attrition
of women in physicianscientist careers.
Major Recommendations
4. The physician-scientist
workforce should be
strengthened by earlier
and more coordinated
efforts to identify and
prepare successful future
investigators who have a
more enduring
commitment to research
careers.